Hospitals that serve more Black patients have poorer nurse staffing, study shows

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Picture two patients receiving acute care: one is hospitalized in a unit where three nurses have five patients and three have six, and another where all six nurses have six patients. Evidence has shown that higher nurse staffing levels are associated with better patient outcomes, including mortality and infection.

This scenario illustrates the impact of findings from a new study led by University of Pennsylvania School of Nursing researchers: that nurse staffing rates are worse in hospitals with the highest percentage of patients who are Black, known as high-Black-serving hospitals or high BSHs. The study is published in the journal Nursing Research.

“It’s particularly concerning because seven out of 10 Black patients are hospitalized in Black-serving hospitals, so there’s really a population implication for the Black patient population,” says first author Eileen T. Lake, a Penn Nursing professor and associate director of the Center for Health Outcomes and Policy Research.

Researchers found that, when adjusting for unit type, nurses in high BSHs had 6% more patients per nurse than low BSHs. This adjustment for unit type is important because a higher proportion of survey respondents in high BSHs worked in adult intensive care units, which care for fewer patients than other units. When also adjusting for characteristics such as whether the hospital is an academic medical center—which deals with more complex cases than a community hospital, Lake says—or is in a metropolitan area, the ratio was 7% higher.

The authors envision two policy solutions, for Black patients to go to better staffed hospitals or to improve staffing in BSHs, but they see the latter as the more feasible option.

Data on the maximum number of patients that nurses were assigned on their last shift came from a 2015 survey of 179,336 registered nurses in 574 hospitals, and the authors expect that nurse staffing distributions remained stable or worsened since then “due to the pandemic’s disproportionate burden on minoritized populations and their providers.”

Past research had found care for Black patients is concentrated in some hospitals, due to residential segregation across the United States, and that high BSHs had higher mortality rates for both Black and white patients. This study also builds on the work of Penn Nursing professor J. Margo Brooks Carthon, who led research finding that Black patients are more sensitive to poorer nurse staffing rates than their white counterparts and that Black patients were disproportionately hospitalized in hospitals with better nurse staffing rates.

The authors of the new paper wrote about the latter finding in relation to their own, “These seemingly contradictory findings may be interpreted as equity as a population level but inequity in localized areas for hospitalized older adults.”

Lake and her collaborators have spent years researching outcome disparities between Black and white patients, she explains, focusing in earlier work on very low birth weight infants and more recently on older adults. They published a study last year that found the percentage of nurses experiencing moral distress during COVID-19 was twice as large in high BSHs.

The researchers also have a paper under review showing that nursing-sensitive indicators—adverse outcomes within a nurse’s purview, such as developing a bloodstream or urinary tract infection—are worse in BSHs. This is based on post-pandemic data. Lake says they are also exploring whether a given hospital is “structurally competent” to care for certain vulnerable groups.

“We’re trying to reveal a variety of core elements to how nursing might be a modifiable system feature that we could better deploy through better nurse staffing,” Lake says. “Another construct we focus on a lot is nurses’ work environment.”

Eileen T. Lake is the Edith Clemmer Steinbright Professor in Gerontology, professor of nursing and sociology, and associate director of the Center for Health Outcomes and Policy Research in the University of Pennsylvania School of Nursing.

Other authors are Hal Chen, Christin Iroegbu, Kimi Li, and Nehemiah Weldeab from Penn Nursing; Jessica G. Smith from the University of Texas at Arlington; Douglas O. Staiger from Dartmouth College; and Jeannette Rogowski from Penn State University.

This research was supported by the American Nurses Foundation and the National Institute of Nursing Research (T32NR007104).